Provider Demographics
NPI:1801047170
Name:DIEWOLD, TERA NICOLE (PA)
Entity type:Individual
Prefix:
First Name:TERA
Middle Name:NICOLE
Last Name:DIEWOLD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1455
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50306-1455
Mailing Address - Country:US
Mailing Address - Phone:515-961-8448
Mailing Address - Fax:
Practice Address - Street 1:6000 UNIVERSITY AVE
Practice Address - Street 2:STE 101
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-8203
Practice Address - Country:US
Practice Address - Phone:515-241-2600
Practice Address - Fax:515-241-2032
Is Sole Proprietor?:No
Enumeration Date:2008-10-06
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN10492363A00000X
IA002114363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant